Coroner's Finding: KROL Riley

0y · Male·hypoxic ischaemic encephalopathy

Riley Krol, a 11-day-old male infant, died from hypoxic ischaemic encephalopathy following emergency caesarean section delivery on 1 March 2005. After artificial rupture of membranes during labour induction, the foetus developed severe, sustained bradycardia lasting approximately 30 minutes before delivery. The emergency caesarean section decision was made at 1:45am, but delivery did not occur until 3:15am—a 90-minute delay unacceptable by any standard. Systemic failures prevented appropriate anaesthetic management: no theatre staff were on duty; the junior anaesthetic registrar could not administer general anaesthesia unsupervised; and the consultant anaesthetist, 30 minutes away, was not adequately informed of the clinical urgency. A spinal anaesthetic was attempted unsuccessfully; an epidural was chosen instead, further delaying delivery. Had the consultant been briefed appropriately or requested to perform general anaesthesia, delivery could have been significantly expedited. Prolonged foetal hypoxia may have rendered the outcome inevitable, but systemic inadequacies at the non-tertiary hospital compounded the tragedy and were remediable.